Healthcare Provider Details

I. General information

NPI: 1750693818
Provider Name (Legal Business Name): DHILEEP JINNA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 07/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 N FRUITLAND BLVD
SALISBURY MD
21801-7261
US

IV. Provider business mailing address

1090 NORTHCHASE PKWY SE SUITE 290
MARIETTA GA
30067-6405
US

V. Phone/Fax

Practice location:
  • Phone: 419-788-5143
  • Fax:
Mailing address:
  • Phone: 678-904-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14536
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: